David Cunningham Director, Central Cardiac Audit Database Richard Charles Chairman, Network Device Survey Group Morag Cunningham CRM Database Coordinator, Central Cardiac Audit Database Adél de Lange Data analyst, Central Cardiac Audit Database
Acknowledgments The implant registration data that allows the construction of reports such as this is contributed on a voluntary basis by all pacemaker implanting hospitals in the United Kingdom. The data is held in the National Pacemaker Database, established in 1977 by Dr Anthony Rickards, and now part of the Central Cardiac Audit Database (CCAD www.ccad.org.uk) which runs the national cardiac audits as part of the National Institute for Cardiovascular Outcomes Research (NICOR), which is part of University College London. Anonymised extracts from the National Pacemaker Database were used to generate this report, with the express permission of the owners of the data, Heart Rhythm UK and the full agreement of the Department of Health Heart Team and HQIP. This national audit is funded as part of the National Clinical Audit & Patient Outcome Programme (NCAPOP), which is managed by the Healthcare Quality Improvement Partnership (HQIP www.hqip.org.uk). The preparation of this report was supported by HQIP. Data collection was carried out by CCAD with support provided from NHS Improvement (www.improvement.nhs.uk) and the Cardiac Networks. The study was performed with the knowledge and support of the British Cardiovascular Society and Heart Rhythm UK. Clinical review of the report was carried out by Dr Richard Charles, Chairman of the Network Devices Survey Group. The report may be downloaded from www.devicesurvey.com British Cardiovascular Society 2
Contents Analysis of Provision of Heart Rhythm Devices for Acknowledgments... 2 Data Quality Statement... 4 Overview of Device Implants in the UK... 6 The Range of New Implant rate 2010... 8 PCTs/LHBs in the Network... 11 Network Age and Sex Distribution... 12 Correcting Implant Rates for Age and Sex... 14 Relative need for Pacemakers and ICDs... 16 New and Total PM and ICD Implants... 17 Geographical location of pacemaker implants... 20 New and Total PM and ICD Implants... 21 CRT implants in this network... 23 Geographical location of Complex Devices implants... 26 Which hospitals serve which PCTs/LHBs?... 28 Pacing Mode for New Implants... 31 Pacing Mode for Sick Sinus Syndrome... 33 ECG Indication for New Implants... 35 Corrected and Actual New Implant Rates... 36 New Implant rate maps for... 41 New pacing implant rate 2010... 42 ICD new implant rate 2010... 43 Pacing Implant Deficit in 2010... 44 Conclusions... 45 3
Data Quality Statement The quality of the analyses in this report is only as good as the quality of the data that supports it. That data is originally submitted by hospitals to the National Pacemaker Database. If there is a deficit in registration, or if registrations do not contain a valid postcode, then analysis gaps are inevitable. Data is then anonymised and extracted to provide the basis of the analysis by the Survey Group. To minimise the risk of deficit errors, a threshold of 98% for registration and postcode completeness is sought for each hospital. Overall network completeness MUST reach 98% or a report will not be issued. Every effort is made to ensure this report is as accurate as possible - however please contact us if you identify any residual problem and we will try to correct the error promptly. Below is a list of important hospitals for this network and their completeness of VALID postcodes during the study period. Valid Postcodes Overall network average 100.00% Main implant Centres CGH.Conquest Hospital 100.00% DGE.Eastbourne DGH 100.00% KSX.Kent & Sussex Hospital 100.00% RSC.Royal Sussex County Hospital 100.00% UCL.University College Hospital 100.00% WRG.Worthing Hospital 100.00% Note: Implant centres shown have implanted at least 10 devices in the network. 4
Data Quality and Completeness Listed below are important fields and their completion rates with valid entries. All Devices ICD, CRT-D & CRT-P Network / Implant Centre Valid Post Code Valid NHS No Valid Gender Valid DOB ECG Symptom Aetiology Target 98.0% 98.0% 98.0% 98.0% 90.0% 90.0% 90.0% England 99.4% 84.0% 99.9% 99.8% 94.5% 94.0% 94.6% This Network 100.0% 89.9% 100.0% 100.0% 95.2% 98.6% 92.9% Conquest Hospital 100.0% 100.0% 100.0% 100.0% 98.8% 98.8% 100.0% Eastbourne DGH 100.0% 99.4% 100.0% 100.0% 99.7% 100.0% 100.0% Royal Sussex County Hospital 100.0% 75.8% 100.0% 100.0% 89.9% 98.8% 80.6% Worthing Hospital 100.0% 98.9% 100.0% 100.0% 99.6% 99.6% 100.0% Network / Implant Centre NYHA Dyspnoea Status CRT-D & ICD LV Function ICD Indication CRT-D & CRT-P QRS duration Overall index of valid data completeness Target 90.0% 90.0% 90.0% 90.0% 90.0% England 63.5% 74.5% 57.5% 27.9% 84.4% This Network 74.2% 92.3% 29.9% 41.8% 85.8% Conquest Hospital 41.9% 100.0% 0.0% 0.0% 81.5% Eastbourne DGH 42.4% 100.0% 0.0% 0.0% 81.7% Royal Sussex County Hospital 96.1% 85.3% 99.0% 62.8% 91.7% Worthing Hospital 100.0% 100.0% 0.0% 0.0% 87.4% Target Achieved Below 50% of target ( - ) = No Implants Notes: 1. Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network. 2. Completeness is shown for all registered procedures for a centre, not just procedures in this network. 3. Overall index is an average for each centre of each field as a ratio of the target, and can exceed 100%. 5
Overview of Device Implants in the UK New pacemakers Comments: The ten year average growth rate is 4.1% Implant rates decreased slightly in England and in Wales. The new PM implant rates decreased significantly in Northern Ireland. There is a substantial shortfall in data submission from Scotland, data has been suppressed post 2008. New pacing rate remains highest in England (528 new implants per million population in 2010). per million population 600 500 400 300 200 100 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year New ICD implants Comments: The ten year average growth rate is 14.9% ICD implant rate remains highest in N Ireland. (There is a substantial shortfall in data submission from Scotland). ICD implant rate increased significantly in England and in Wales in 2010. per million population 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 6
New CRT implants Comments New CRT rate increased significantly in England and remained the highest rate. The new CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland). per million population 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year Total CRT implants Comments The total CRT rate rose significantly in England for the last three years. Total CRT implants Rate was highest in England (114 new implants per million population in 2010). The total CRT rate also increased in N Ireland, Wales and Scotland in 2010. (There is a substantial shortfall in data submission from Scotland). per million population 140 120 100 80 60 40 20 0 England Wales Scotland N Ireland 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 7
The Range of New Implant rate 2010 grey line represents national average Pacemaker New Implant rate 2010 adjusted for age and sex Dorset Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Kent Cardiovascular Network North West London Cardiac and Stroke Network North of England Cardiovascular Network South West London Cardiac Network Cheshire & Merseyside Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Greater Manchester & Cheshire Cardiac Network South Central Cardiovascular Network West Yorkshire Cardiac Network Black Country Cardiovascular Network Essex Cardiac and Stroke Network North Central London Cardiac & Stroke Network Anglia Stroke and Heart Network North Trent Network of Cardiac Care South East London Cardiac & Stroke Network North East London Cardiac and Stroke Network Peninsula Heart and Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network East Midlands Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Herefordshire and Worcestershire Cardiac Network Coventry & Warwickshire Cardiovascular Network 0 100 200 300 400 500 600 700 800 8
The Range of New Implant rate 2010 grey line represents national average ICD New Implant rate 2010 adjusted for age and sex North East London Cardiac and Stroke Network Dorset Cardiac Network Kent Cardiovascular Network Bedfordshire and Hertfordshire Heart and Stroke Network North Central London Cardiac & Stroke Network South East London Cardiac & Stroke Network North West London Cardiac and Stroke Network South Central Cardiovascular Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network North of England Cardiovascular Network East Midlands Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network Surrey Heart & Stroke Network Black Country Cardiovascular Network West Yorkshire Cardiac Network North Trent Network of Cardiac Care South West London Cardiac Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Coventry & Warwickshire Cardiovascular Network Greater Manchester & Cheshire Cardiac Network Essex Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Peninsula Heart and Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Anglia Stroke and Heart Network Cardiac and Stroke Networks in Cumbria and Lancashire Herefordshire and Worcestershire Cardiac Network 0 20 40 60 80 100 120 140 9
The Range of Total Implant rate 2010 grey line represents national average All CRT Total Implant rate 2010 adjusted for age and sex includes CRTD and CRTP North West London Cardiac and Stroke Network Birmingham, Sandwell and Solihull Cardiac and Stroke Network Cheshire & Merseyside Cardiac Network Greater Manchester & Cheshire Cardiac Network South East London Cardiac & Stroke Network West Yorkshire Cardiac Network South West London Cardiac Network Dorset Cardiac Network Bedfordshire and Hertfordshire Heart and Stroke Network Kent Cardiovascular Network North Central London Cardiac & Stroke Network Black Country Cardiovascular Network Surrey Heart & Stroke Network North & East Yorkshire and Northern Lincolnshire Cardiac Network Cardiac and Stroke Networks in Cumbria and Lancashire Anglia Stroke and Heart Network South Central Cardiovascular Network Peninsula Heart and Stroke Network North East London Cardiac and Stroke Network Coventry & Warwickshire Cardiovascular Network Herefordshire and Worcestershire Cardiac Network Avon, Gloucestershire, Wiltshire & Somerset Cardiac and Stroke Network Shropshire & Staffordshire Cardiac Network Essex Cardiac and Stroke Network North of England Cardiovascular Network East Midlands Cardiac and Stroke Network North Trent Network of Cardiac Care 0 20 40 60 80 100 120 140 160 180 200 10
PCTs/LHBs in the Network Total population 1.10 million. Code PCT/LHB Population Old PCT (where relevant*) 5LQ Brighton and Hove City 251,428 5P6 West Sussex 130,700 5FK.Mid-Sussex 5P6 West Sussex 216,300 5L8.Adur, Arun and Worthing 5P7 East Sussex Downs and Weald 330,148 5P8 Hastings and Rother 176,075 * The revision of PCT boundaries in 2006 has resulted in some PCTs being "split" across Cardiac Network boundaries. In these cases only the relevant portion of the new PCT will be included in this report, as defined by the old PCT boundaries. 11
Network Age and Sex Distribution Population data from ONS, based on mid-2006 population estimates Data for England Average age: 39.5 (for comparison): % aged 70+: 11.60% Population PCT / LHB Age Male Female Age Male Female 5LQ Population: 251,428 0-5: 6,794 6,708 46-50: 8,099 7,804 Average age: 39.4 6-10: 6,101 6,006 51-55: 6,693 6,728 % aged 70+: 11.2% 11-15: 6,265 6,113 56-60: 6,697 6,468 5P6 [5FK] 16-20: 7,317 8,154 61-65: 4,907 5,393 21-25: 10,091 11,822 66-70: 4,583 4,621 26-30: 10,291 9,880 71-75: 3,746 4,588 31-35: 11,825 10,573 76-80: 3,027 4,376 36-40: 11,887 10,759 81-85: 2,319 3,817 41-45: 10,465 10,107 85+: 1,916 4,488 Population: 130,800 0-5: 3,900 3,600 46-50: 4,700 4,800 Average age: 41.1 6-10: 4,300 4,000 51-55: 4,500 4,700 % aged 70+: 12.3% 11-15: 4,600 4,000 56-60: 4,800 5,000 5P6 [5L8] 16-20: 4,200 3,800 61-65: 3,300 3,400 21-25: 3,000 2,900 66-70: 2,800 3,000 26-30: 3,100 3,200 71-75: 2,500 2,900 31-35: 3,900 4,500 76-80: 1,800 2,500 36-40: 5,200 5,300 81-85: 1,200 2,200 41-45: 5,000 5,200 85+: 900 2,100 Population: 216,200 0-5: 5,800 5,400 46-50: 6,500 6,700 Average age: 44.3 6-10: 6,300 6,000 51-55: 6,400 6,800 % aged 70+: 18.3% 11-15: 6,700 6,400 56-60: 7,300 7,800 * Older than national average Brighton and Hove City West Sussex [Mid-Sussex] West Sussex [Adur, Arun and Worthing] 16-20: 6,100 5,600 61-65: 5,600 6,300 21-25: 4,600 4,600 66-70: 5,300 6,300 26-30: 4,900 5,200 71-75: 5,000 6,400 31-35: 6,400 7,000 76-80: 4,400 6,200 36-40: 7,800 8,100 81-85: 3,300 5,800 41-45: 7,300 7,500 85+: 2,200 6,200 12
Population PCT / LHB Age Male Female Age Male Female 5P7 Population: 330,148 0-5: 8,488 8,082 46-50: 11,241 11,846 Average age: 44.2 6-10: 9,501 9,058 51-55: 10,188 10,832 % aged 70+: 16.9% 11-15: 10,484 9,756 56-60: 11,523 12,557 * Older than national average 5P8 16-20: 10,392 9,994 61-65: 10,296 11,248 21-25: 7,654 7,327 66-70: 8,359 9,470 26-30: 6,564 7,221 71-75: 7,652 9,008 31-35: 7,496 8,503 76-80: 6,501 8,744 36-40: 10,490 10,969 81-85: 4,637 7,207 41-45: 11,941 12,760 85+: 3,813 8,346 Population: 176,075 0-5: 4,447 4,047 46-50: 5,808 6,120 Average age: 44.4 6-10: 5,078 4,957 51-55: 5,511 5,650 % aged 70+: 17.1% 11-15: 5,614 5,365 56-60: 6,378 6,791 * Older than national average East Sussex Downs and Weald Hastings and Rother 16-20: 5,571 5,317 61-65: 5,589 5,996 21-25: 4,367 3,894 66-70: 4,578 5,145 26-30: 3,406 3,888 71-75: 4,162 4,934 31-35: 3,943 4,426 76-80: 3,401 4,468 36-40: 5,465 5,910 81-85: 2,613 3,989 41-45: 6,238 6,401 85+: 1,942 4,666 Note: A PCT is considered to be older than average the percentage for aged 70+ is greater than or equal to 13.1% and it is considered to be younger than average if the percentage for aged 70+ is less than or equal to 10.3%. 13
Correcting Implant Rates for Age and Sex Calculating Need Most pacemakers are implanted for conduction system disease, which is predominantly a disease of the elderly. The graph (right) shows the percentage of the population in 5 year age bands, and the percentage of pacemaker implants. Only 11% of the population are aged 70 or more, but they receive 76% of all pacemaker implants. Men also receive more pacemakers than women. Although the national average new implant rate is 528, it reaches more than 11,000 in men aged more than 90 (right). So the proportion of older people in a local population will strongly influence how many pacemakers need to be implanted. If we examine closely the age and sex distribution of the local population of a PCT (LHB in Wales) or Network, we can work out how many pacemakers we would EXPECT to see implanted, compared to the national average. The ratio of the local and national rate is called the Relative Need, and we calculate this for both pacemakers and ICDs. So, for example, in North East London the population is relatively young. Only 8% are aged 70 or more, compared to the national average of 11%. This means that this network doesn't need as many pacemaker implants relative to the nation as a whole. Their Relative Need for Pacing is calculated to be 80% of the national average. In contrast, Sussex has a more elderly population, with 16% aged 70 or over. Their Relative Need for Pacing is 140%. 14
Using Relative Need We want to make a fair and valid comparison between PCTs/LHBs, Networks and the National Average. That means we should correct for relative need. So, for example if North London has a pacing rate of 480, and Sussex has a rate of 840, are they different? North London's adjusted rate is 480 divided by relative need (80%) = 600. Sussex's adjusted rate is 840 divided by 140% = 600. So the adjusted rates for these two areas are the same, despite the major apparent difference in their unadjusted rates. Implantable Defibrillators The diseases for which ICDs are implanted are not the same as for pacemakers, and tend to occur in slightly younger people. These diseases are principally ischaemic heart disease and cardiomyopathy. We therefore need to calculate a separate relative need factor for ICDs. The graph (right) of new ICD implant rate in 2006 shows that ICDs are also predominantly implanted in older people. Unlike pacemakers, the ICD implant rate starts to decline over the age of 75. The influence of a local elderly population of need for ICDs will therefore still be present, but just slightly less in magnitude than for pacemakers. Sussex, for instance, has a relative ICD need of 138%. 15
Relative need for Pacemakers and ICDs Indicative new implant rate Pacemakers: 528 ICD: 72 (average for England 2010) Average age: 39.44 A PCT with a relatively OLD population will need relatively MORE pacemaker and ICD implants compared to a PCT with a young population, because the incidence of indications for pacing and ICD is higher in older people. Average age Expected pacing new implant rate Compared to national average Expected ICD new implant rate Compared to national average 5LQ Brighton and Hove City 39.4 481 91.1% 61 85% 5P6 West Sussex [5FK] 41.1 560 106.2% 73 102% 5P6 West Sussex [5L8] 44.3 805 152.5% 83 117% 5P7 East Sussex Downs and Weald 44.2 761 144.2% 87 122% 5P8 Hastings and Rother 44.4 753 142.8% 88 123% Cardiac Network - Relative Need for New Implant Rate 669 126.89% 79 111.19% England (for comparison) England 528 100% 72 100% Note: "Expected" pacing and ICD rates are relative to national average rate, but are corrected depending on the age and sex distribution of the local population (see Page 12). For Pacemakers, the expected implant rate will be higher if the percentage of older people in the PCT is higher. For ICDs, the same general rule applies, but the pattern is slightly different, because ICD implant rates peak at age 70 and then decrease rapidly. These relative rates will be used to correct the observed rates and produce a truer reflection of local implant rates vs. local need. 16
New and Total PM and ICD Implants Pacemakers The following hospitals implanted pacemakers in patients from this cardiac network in 2010. A new pacemaker centre will implant nearly 100% new implants, and the longer a centre has been implanting, the higher the percentage of replacements implants. The national average for replacement implants is 21.79% of the total workload. This should always be borne in mind when forecasting future workload. 2010 Replacement implants Centre New Implants Total Implants % of total RSC Royal Sussex County Hospital 305 329 7.29% DGE Eastbourne DGH 188 277 32.13% CGH Conquest Hospital 156 198 21.21% WRG Worthing Hospital 140 183 23.50% KSX Kent & Sussex Hospital 29 31 6.45% KCH King's College Hospital 6 8 25.00% ESU East Surrey Hospital 7 7 LBH London Bridge Hospital 3 6 50.00% HH Harefield Hospital 2 4 50.00% NHB Royal Brompton Hospital 3 3 UCL University College Hospital 1 2 50.00% STR St Richards Hospital 2 2 STH St Thomas' Hospital 2 GUY Guys Hospital 2 GEO St George's Hospital 2 WYT Wythenshawe Hospital 1 1 MAI Maidstone General Hospital 1 1 NOR Norfolk and Norwich Hospital 1 1 PAP Papworth Hospital 1 RFH Royal Free Hospital 1 1 MAY Mayday University Hospital 1 SGH Southampton General Hospital 1 1 BAT Royal United Hospital Bath 1 1 ANT St Anthony's Hospital 1 HHW Wellington Hospital 1 1 WHH William Harvey Hospital 1 1 BRO Princess Royal University Hospital 1 1 17
Pacemaker implant trends 700 Pacemaker New Implant Rate adjusted for age and sex of network population 600 per million population 500 400 300 200 England 100 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 800 Pacemaker All Implant Rate adjusted for age and sex of network population 700 600 per million population 500 400 300 200 100 England 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 18
Pacemaker new implant rate in context Is the PCT new implant rate too high or too low, compared to the national target of 700? The funnel plot below shows the national target (grey line) and the upper (green) and lower (red) control limits. PCTs are shown in light blue circles, and this network's PCTs are shown as larger blue circles. If a PCT's rate is above the green line, it may be excessively high. If it is below the red line, it may be too low. 1200 1000 PCT New Implant Rate National Target Upper Control Limit Low er Control Limit PCT in This Netw ork significantly above national target PCT pacemaker new implant rate 800 600 400 consistent w ith national target 200 significantly below national target 0 0 200,000 400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 PCT population Funnel plots are a way of displaying performance against a national average or target. Here, the national target of 700 is shown as a horizontal grey line. The small blue dots represent the new implant rate (yaxis) in each PCT in the country plotted against that PCTs population (x-axis). The individual PCTs in THIS NETWORK are plotted as larger blue circles. The CONTROL LIMITS determine whether a PCT's new implant rate is significantly greater than (green line) or less than (red line) the national target. The statistical significance level was chosen to ensure that the total risk of one or more PCTs being outside the control limits by random chance is no more than 5%. 19
Geographical location of pacemaker implants 20
New and Total PM and ICD Implants Implantable Cardioverter Defibrillators (ICDs) The following hospitals implanted ICDs in patients from this cardiac network in 2010. 2010 Replacement implants Centre New Implants Total Implants % of total RSC Royal Sussex County Hospital 23 34 32.35% WRG Worthing Hospital 21 22 4.55% CGH Conquest Hospital 20 22 9.09% DGE Eastbourne DGH 11 17 35.29% UCL University College Hospital 4 7 42.86% STH St Thomas' Hospital 3 5 40.00% NHB Royal Brompton Hospital 2 3 33.33% GEO St George's Hospital 2 3 33.33% KSX Kent & Sussex Hospital 1 1 QAP Queen Alexandra Hospital Portsmouth 1 1 STM St Mary's Hospital Paddington 1 1 LBH London Bridge Hospital 1 1 21
ICD implant trends 90 ICD New Implant Rate adjusted for age and sex of network population 80 70 per million population 60 50 40 30 20 10 0 England 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 120 ICD All Implant Rate adjusted for age and sex of network population 100 per million population 80 60 40 20 0 England 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 22
CRT implants in this network Heart failure is a major and growing public health problem in all Western countries, and is associated with high morbidity and mortality despite optimal medical therapy. Clinical trials of high scientific quality published in recent years have consistently found that cardiac resynchronisation therapy (CRT) improves symptoms, quality of life, exercise tolerance and survival in appropriately chosen patients with advanced heart failure and evidence of left ventricular dyssynchrony who are refractory to optimal medical therapy. CRT involves simultaneous pacing of the left and right ventricles (CRT-P), and may be combined, in the same device, with a defibrillation function (CRT-D). Although CRT involves pacing the heart, it should not be confused with 'classical' pacing for bradycardia - the vast majority of CRT recipients do not require pacing for bradycardia. The function of pacing is to make the ventricles beat at the same time ('resynchronisation'). Within this report, data for CRT-P and CRT-D are quantified separately from pacing and ICD data respectively. In the UK, CRT is provided predominantly by tertiary centres with a special interest in cardiac device therapy. Despite the high prevalence of heart failure, uptake of CRT in the UK is amongst the lowest in Western Europe. NICE published guidelines on the cost effectiveness of CRT in 2007, and it is expected that clinical demand for CRT therapy will continue to rise significantly in coming years. CRT implanting hospitals in this network CRT-D CRT-P 2008 Royal Sussex County Hospital 23 22 Eastbourne DGH 19 10 Conquest Hospital 8 3 Worthing Hospital 4 6 St George's Hospital 2 London Bridge Hospital 2 King's College Hospital 1 Royal Brompton Hospital 1 Barts and the London 1 Southampton General Hospital 1 St Thomas' Hospital 1 University College Hospital 1 CRT-D CRT-P 2009 Royal Sussex County Hospital 14 19 Eastbourne DGH 13 11 Conquest Hospital 11 13 Worthing Hospital 5 8 Royal Brompton Hospital 4 1 St Thomas' Hospital 2 1 University College Hospital 1 1 King's College Hospital 2 Harefield Hospital 1 23
2009 Wellington Hospital 1 Princess Royal University Hospital 1 Harley Street Clinic 1 St Mary's Hospital Portsmouth 1 Maidstone General Hospital 1 CRT-D CRT-P 2010 Royal Sussex County Hospital 40 30 Eastbourne DGH 14 8 Conquest Hospital 9 10 Worthing Hospital 9 6 St Thomas' Hospital 2 1 Royal Brompton Hospital 2 Southampton General Hospital 2 King's College Hospital 1 1 University College Hospital 2 24
CRT implant trends 140 120 100 CRT New Implant Rate adjusted for age and sex of network population England per million population 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year 180 CRT All Implant Rate adjusted for age and sex of network population 160 140 England per million population 120 100 80 60 40 20 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 year Note: Low voltage CRT devices ( CRT-P) pace both the left and right ventricles. High voltage CRT devices (CRT-D) combine this function with a defibrillation capability. 25
Geographical location of Complex Devices implants 26
The European Picture European data for 2010 shows that the UK has average CRT implant rates compared to the Western Europe implant rates, and far below the rate in the U.S.A.. Greece Spain Ireland Portugal Finland Norway Switzerland Sweden France Aus tria UK Belgium Denmark Netherlands Czech Republic Germany Italy Total CRT-P & CRT-D Implants 2010 0 50 100 150 200 250 27
Which hospitals serve which PCTs/LHBs? all implants for this cardiac network in 2010 Pacemakers 5LQ.Brighton and Hove City Total Implants 2010 RSC Royal Sussex County Hospital 155 WRG Worthing Hospital 1 LBH London Bridge Hospital 1 PAP Papworth Hospital 1 DGE Eastbourne DGH 1 5P6.West Sussex [5FK] Total Implants 2010 RSC Royal Sussex County Hospital 69 ESU East Surrey Hospital 7 KCH King's College Hospital 4 KSX Kent & Sussex Hospital 3 GEO St George's Hospital 2 HH Harefield Hospital 2 LBH London Bridge Hospital 2 STH St Thomas' Hospital 1 NHB Royal Brompton Hospital 1 5P6.West Sussex [5L8] Total Implants 2010 WRG Worthing Hospital 181 RSC Royal Sussex County Hospital 19 UCL University College Hospital 2 STR St Richards Hospital 2 ANT St Anthony's Hospital 1 BAT Royal United Hospital Bath 1 SGH Southampton General Hospital 1 NOR Norfolk and Norwich Hospital 1 NHB Royal Brompton Hospital 1 5P7.East Sussex Downs and Weald Total Implants 2010 DGE Eastbourne DGH 265 RSC Royal Sussex County Hospital 77 KSX Kent & Sussex Hospital 26 CGH Conquest Hospital 4 KCH King's College Hospital 4 WYT Wythenshawe Hospital 1 HHW Wellington Hospital 1 GUY Guys Hospital 1 MAY Mayday University Hospital 1 MAI Maidstone General Hospital 1 28
NHB Royal Brompton Hospital 1 BRO Princess Royal University Hospital 1 STH St Thomas' Hospital 1 5P8.Hastings and Rother Total Implants 2010 CGH Conquest Hospital 194 DGE Eastbourne DGH 11 RSC Royal Sussex County Hospital 9 LBH London Bridge Hospital 3 HH Harefield Hospital 2 KSX Kent & Sussex Hospital 2 WHH William Harvey Hospital 1 RFH Royal Free Hospital 1 GUY Guys Hospital 1 Implantable Cardioverter Defibrillators (ICDs) 5LQ.Brighton and Hove City Total Implants 2010 RSC Royal Sussex County Hospital 9 UCL University College Hospital 1 STM St Mary's Hospital Paddington 1 5P6.West Sussex [5FK] Total Implants 2010 RSC Royal Sussex County Hospital 10 GEO St George's Hospital 3 UCL University College Hospital 1 5P6.West Sussex [5L8] Total Implants 2010 WRG Worthing Hospital 22 RSC Royal Sussex County Hospital 4 NHB Royal Brompton Hospital 2 UCL University College Hospital 1 5P7.East Sussex Downs and Weald Total Implants 2010 DGE Eastbourne DGH 17 RSC Royal Sussex County Hospital 10 UCL University College Hospital 4 STH St Thomas' Hospital 3 NHB Royal Brompton Hospital 1 CGH Conquest Hospital 1 QAP Queen Alexandra Hospital Portsmouth 1 5P8.Hastings and Rother Total Implants 2010 CGH Conquest Hospital 21 STH St Thomas' Hospital 2 KSX Kent & Sussex Hospital 1 LBH London Bridge Hospital 1 RSC Royal Sussex County Hospital 1 29
Cardiac Resynchronisation Therapy (CRT) 5LQ.Brighton and Hove City Total Implants 2010 RSC Royal Sussex County Hospital 30 5P6.West Sussex [5FK] Total Implants 2010 RSC Royal Sussex County Hospital 12 NHB Royal Brompton Hospital 2 STH St Thomas' Hospital 1 KCH King's College Hospital 1 5P6.West Sussex [5L8] Total Implants 2010 WRG Worthing Hospital 15 RSC Royal Sussex County Hospital 3 SGH Southampton General Hospital 1 UCL University College Hospital 1 5P7.East Sussex Downs and Weald Total Implants 2010 RSC Royal Sussex County Hospital 23 DGE Eastbourne DGH 22 UCL University College Hospital 1 KCH King's College Hospital 1 SGH Southampton General Hospital 1 STH St Thomas' Hospital 1 5P8.Hastings and Rother Total Implants 2010 CGH Conquest Hospital 19 RSC Royal Sussex County Hospital 2 STH St Thomas' Hospital 1 30
Pacing Mode for New Implants for this cardiac network Pacemakers Mode % for this network England % Atrial based modes DDDR 67.30% 61.54% DDD 0.71% 4.53% AAIR 0.59% 0.52% AAI 0.00% 0.05% DDI 0.00% 0.06% DDIR 0.00% 0.02% Other 0.12% 0.15% Ventricular based modes VVIR 29.75% 31.28% VVI 1.53% 1.57% VDDR 0.00% 0.04% VDD 0.00% 0.25% Note: The Mode table percentage calculations do not include any records where the mode was blank or unknown. Network England Ventricular based 31% Blank/ Unknown 0.5% Ventricular based 33% Blank/ Unknown 1% Atrial based 69% Atrial based 66% Note: The Network and England charts percentage segments are calculated based on the records in the Mode table but also include all records where the mode was blank or unknown. 31
Pacing Mode for New Implants major implanting hospitals in this cardiac network VVI VVIR AAI AAIR DDD DDDR VDD VDDR Atrial Based Pacing NATIONAL 1.6% 31.4% 0.0% 0.5% 4.5% 61.7% 0.3% 0.0% 66.8% This Network 1.5% 29.8% 0.0% 0.6% 0.7% 67.4% 0.0% 0.0% 68.7% CGH.Conquest Hospital 0.6% 33.3% 0.0% 0.0% 0.0% 66.0% 0.0% 66.0% DGE.Eastbourne DGH 0.5% 22.5% 0.0% 0.0% 0.0% 77.0% 0.0% 77.0% RSC.Royal Sussex County Hospital 0.0% 29.8% 0.0% 0.0% 0.7% 69.5% 0.0% 70.2% WRG.Worthing Hospital 7.9% 37.9% 0.0% 2.9% 0.0% 51.4% 0.0% 54.3% Note: Implant centres shown have contributed at least 5% of Pacemaker implant activity in the network. Note: The Mode table for major implanting hospitals percentage calculations do not include any records where the mode was blank or unknown. NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. 32
Pacing Mode for Sick Sinus Syndrome There is ample evidence from major clinical trials and support from NICE guidelines (NICE Technology Appraisal 88, 2005) that use of ventricular pacing modes in patients with sick sinus syndrome can lead to poor outcomes, notably an increased incidence of atrial fibrillation and pacemaker syndrome. Pacing modes in sick sinus syndrome should be atrial based (i.e. dual chamber or atrial). The Western European average in 2005 was 92% atrial based pacing for SSS. In the UK the average was 81% in 2009 and 84% in 2010. Any percentage of ventricular based pacing greater than 10% has been shaded pink, and may be considered higher than desirable. A percentage greater than 20% is considered definitely too high and is shown in a shaded red box. Percentages greater than 50% are shown shaded black. NB: the % of atrial based pacing shown for a centre applies only to patients residing in THIS NETWORK and may differ overall. New Implants for Sick Sinus Syndrome in this network Atrial-based New Implants for SSS in this network Ventricular-based New Implants for SSS in this network CGH.Conquest Hospital 39 84.6% 15.4% DGE.Eastbourne DGH 55 92.7% 7.3% RSC.Royal Sussex County Hospital 48 83.3% 16.7% WRG.Worthing Hospital 43 83.7% 16.3% Note: Any hospital in the network not in this list did not code at least 10 implants as SSS. Note: For this analysis only ECG codes E1-E5 are used NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. References 1. TA88 Bradycardia - dual chamber pacemakers: Information for the public. NICE 23 February 2005. http://www.nice.org.uk/ta88 33
The European Picture Atrial based pacing in the UK is low compared to most of Europe. Spain Turkey Netherlands UK Norway LATVIA Belgium FR Yugoslavia France Austria Sweden Denmark % Atrial-based pacing for Sick Sinus Syndrome 2003 (most recent survey) 60% 65% 70% 75% 80% 85% 90% 95% NB: As from 2007, mode is based on the maximum mode of which the device is capable and not the mode at the end of the procedure. 34
ECG Indication for New Implants Complete HB Incomplete HB AF + HB/brady Sick sinus syndrome Other NATIONAL 22.7% 22.8% 23.5% 27.5% 6.2% This Network 25.8% 21.4% 20.5% 25.5% 6.8% 5LQ.Brighton and Hove City 34.7% 24.0% 16.5% 20.7% 4.1% 5P6.West Sussex [5FK] 38.2% 26.5% 16.2% 16.2% 2.9% 5P6.West Sussex [5L8] 26.6% 22.2% 13.9% 29.7% 7.6% 5P7.East Sussex Downs and Weald 22.7% 18.9% 21.6% 26.5% 10.2% 5P8.Hastings and Rother 18.2% 20.6% 29.7% 27.3% 4.2% AF: atrial fibrillation HB: heart block Brady: bradycardia 35
Corrected and Actual New Implant Rates Pacemakers Expected and Actual New Implant Rates Explanatory note: The "Raw" new implant rate is the actual implant rate of new pacemakers per million population in each PCT. The "corrected" rate is the raw rate, adjusted for relative need so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs and with network and national averages should be made using corrected rate. England Average 528 Network average (unadjusted) 771 Network average (corrected for age and sex) 565 Population Relative need for PM New Implant Rate 2010 Raw Corrected 5LQ Brighton and Hove City 251,428 91.1% 593 651 5P6 West Sussex [5FK] 130,700 106.2% 613 577 5P6 West Sussex [5L8] 216,300 152.5% 755 495 5P7 East Sussex Downs and Weald 330,148 144.2% 855 593 5P8 Hastings and Rother 176,075 142.8% 1007 705 36
How much does the implant rate vary in this network? Of course there will always be some random variation in implant rate. This NORMAL CAUSE variation is not considered likely to exceed 5% of the total implant rate for pacing. Variation IN EXCESS of 10% may be considered due to another (SPECIAL) cause, such as referral patterns or varying implantation policies between trusts. Variability Index for this Cardiac Network 13.1% 1% RATING: small variation in implant rates between PCTs 37
New Pacemaker Implant Rates The Western European average new implant rate for 2003 and 2004 was 700 per million population. This figure is also now the HRUK target and will be used as the basis for comparison. England Average 528 Network average (unadjusted) 771 Network average (corrected for age and sex) 565 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 700 5LQ Brighton and Hove City 251,428 651-7% 5P6 West Sussex [5FK] 130,700 577-18% 5P6 West Sussex [5L8] 216,300 495-29% 5P7 East Sussex Downs and Weald 330,148 593-15% 5P8 Hastings and Rother 176,075 705 1% 38
Corrected and Actual New Implant Rates Implantable Cardioverter Defibrillators (ICDs) Explanatory note: The "Raw" new implant rate is the actual implant rate of new ICDs per million population in each PCT. The "Corrected" rate is the raw rate, adjusted for relative need - so if a PCT has an aging population, its relative need is > 100% and its corrected rate will be reduced to reflect that need. Comparisons between PCTs should be made using Corrected rate. England Average 72 Network average (unadjusted) 82 Network average (corrected for age and sex) 73 Population Relative need for ICD New Implant Rate 2010 Raw Corrected 5LQ Brighton and Hove City 251,428 85.3% 28 33 5P6 West Sussex [5FK] 130,700 102.4% 70 67 5P6 West Sussex [5L8] 216,300 116.8% 117 99 5P7 East Sussex Downs and Weald 330,148 122.0% 82 67 5P8 Hastings and Rother 176,075 123.3% 125 101 39
New ICD Implant Rates A target figure of 100 implants per million is used as a basis for comparison, based on recent NICE guidance. England Average 72 Network average (unadjusted) 82 Network average (corrected for age and sex) 73 Population Corrected New Implant Rate 2010 Deficit/ Excess 2010 compared to rate of 100 5LQ Brighton and Hove City 251,428 33-67% 5P6 West Sussex [5FK] 130,700 67-33% 5P6 West Sussex [5L8] 216,300 99-1% 5P7 East Sussex Downs and Weald 330,148 67-33% 5P8 Hastings and Rother 176,075 101 1% 40
New Implant rate maps for Sussex Heart Network 41
New pacing implant rate 2010 comparison with Heart Rhythm UK target (700) Pacemaker New Implants 2010 adjusted for age and sex compared to target figure of 700 per million West Sussex [5L8] West Sussex [5FK] East Sussex Downs and Weald Brighton and Hove City Hastings and Rother -35% -30% -25% -20% -15% -10% -5% 0% 5% 42
ICD new implant rate 2010 ICD New Implants 2010 adjusted for age and sex compared to target figure of 100 per million Brighton and Hove City East Sussex Downs and Weald West Sussex [5FK] West Sussex [5L8] Hastings and Rother -80% -70% -60% -50% -40% -30% -20% -10% 0% 10% 43
Pacing Implant Deficit in 2010 comparison with HRUK recommendations The graph shows the NUMBER of additional new pacemakers implants that each PCT needs to implant to bring them up to the HRUK target rate. Deficit in New Pacemaker Implants 2010 compared to Heart Rhythm UK target rate of 700 10 0-10 -20 Hastings and Rother Brighton and Hove City West Sussex [5FK] East Sussex Downs and Weald West Sussex [5L8] -30-40 -50-60 -70-80 44
Conclusions There is a very high need for devices across the network due to the aged population. The average excess need compared to England is 27%. The network as a whole also has an 11% higher need for ICDs than average. The network new pacemaker implant rate increased significantly and is above the national average, but below the national target. The network new ICD implant rate increased and tracks the national average. Although the total CRT implant rate increased significantly it is below the national average. The proportion of atrial based pacing (69%) is higher than the national average of 66%. Royal Sussex County Hospital (17%), Worthing Hospital (16%) and Conquest Hospital (15%) have higher than desirable rates of ventricular based pacemaker implants for sick sinus syndrome; this is not compliant with NICE TAG 88 (2005). There are significant clinical data quality and completeness issues (see p5) at Conquest, Eastbourne and Worthing Hospitals. The quality of the audit will be enhanced if these issues can be addressed in the data returns for 2012. 45